Putting Aboriginal Health First

Webinar summary

9 May 2018

It is well recognised that Aboriginal and Torres Strait Islander people face barriers to accessing effective healthcare and community programs. This webinar provides you with knowledge of free NSW Health funded services that can assist and support you in your care of Aboriginal and Torres Strait Islander communities who may benefit from a healthier lifestyle and/or who are struggling with overweight and obesity. We discuss the Aboriginal Go4Fun, Aboriginal Knockout Health Challenge and the Get Healthy Coaching and Information Service programs, including positive outcomes, referral pathways and how, as a GP you can utilise feedback from these services as a part of ongoing monitoring and improvement of patient health.

Presenters

Dr Tim Senior

Cris Carriage

Dr Kate Reid

Jaimee Moyle

Sammi: Good evening everybody and welcome to this evenings twilight online Putting Aboriginal Health First webinar. My name is Samantha, your host for this evening. Before we make a start, I would like to make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders past and present. So I will introduce our presenters for this evening. So, we are joined by Dr Tim Senior tonight. He is an RACGP medical advisor for the Faculty of Aboriginal and Torres Strait Islander Health, and a GP at Tharawal Aboriginal Corporation. We are joined by Christine Carriage. She is a manager at the Aboriginal Health College. And we have also got two representatives with us tonight from the New South Wales Ministry of Health. We have Dr Kate Reid. She is the Program Manager for the Get Healthy Service from the New South Wales Office of Preventative Health. And we have Jamiee Moyle who is the State Project Officer for the Go4Fun program, also from the New South Wales Office of Preventative Health. In saying that, I will hand over to Dr Tim Senior now to take us through the learning outcomes for this evening.

Tim: Good evening everyone. Thank you for joining us this evening. We love doing webinars because we see people from across the whole of New South Wales and Australia. So the learning outcomes is just a way of saying what we want people to get out of this session, and so we hope by the end of this activity, you should be able to list specific programs which are available for Aboriginal and Torres Strait Islander people, who might benefit from adopting healthier lifestyle habits. We hope you might be able to discuss the elements of the New South Wales based healthy lifestyle services for Aboriginal and Torres Strait Islander people, such as the Aboriginal Go4Fun, the Get Healthy information and coaching service and the Aboriginal Knockout Health Challenge and including facilitating positive outcomes from those. We are going to talk about incorporating referral of eligible patients into your consultations using their referral mechanisms. I am going to say a little bit about setting up patient recall and utilising feedback from the programs as part of your ongoing monitoring. So that is what we hope to get out of tonight.

We have got a lot to get through, so we probably start, launch straight into it now. There are essentially all sorts of statistics that I think we could go through and facts about obesity, but I think for the purposes for talking about obesity and Aboriginal and Torres Strait Islander people, there are just two really important things to know, and one of these is obesity has a social gradient which is actually that – what that means is that obesity is not distributed evenly across the population and we will talk about how it is distributed through the population and the implications of that for our Aboriginal and Torres Strait Islander patients, but also that what we see now is actually the result of history, and Chris will be talking a little bit about that in a few moments’ time. So just talking about a social gradient and obesity. The next slide gives you a good picture of this. So essentially you can see on the left there, the least disadvantaged people, the most advantaged people, and on the right, the most disadvantaged people and you can see much higher rates of obesity in more disadvantaged people. And actually the target that has been set there, just on the 25% of people being obese, we need to work very much on people, patients who are most disadvantaged if we are going to make headway on that target. This is from the tracker by socioeconomic status from 2017 which was published earlier, late last year. The other thing to notice about this is that in obesity, these are fairly well pronounced. It is less well-pronounced in overweight, but in obesity it is very clear.

If we move onto the next slide, we will see some of the reasons for this. And again, just focussing on the right here is our graph from a similar publication showing us that physical activity is also distributed according to social class essentially, and that the most disadvantaged people have less activity in their life. And a lot of that is related to the conditions people are living in, like we often expect people to join a gym, we expect people to do walking or cycling, but actually the people need money and decent environments and parks they can get around in, and so the environment people live in often results in that. And then, that text on the right is taken from a paper, actually published in South Australia, and the take home message from that is that food takes up a really high proportion of household budgets in those without much money, particularly those on welfare. So there is a real, so we need to take that sort of thing into account when we say to our patients, particularly our Aboriginal and Torres Strait Islander patients, “oh, you need to do more exercise” and “you need to eat healthily.” We may need to be really aware of people’s conditions in which they live in order to tailor that advice around food that they can afford and physical activities that they can afford to do, too.

So moving on to the next slide. I am going to invite Chris to talk about some of the things that have happened in history that also lead to the things that we see happening for our patients in our own consultations.

Christine: Hi everyone. Hope you are well. How are you, you cannot answer me that. So, I guess the that this is just really quite brief and so when you think about historical factors in Aboriginal people’s lives and that stuff around hunting and gathering, and we look at the east coast of Australia and how that was devastated by colonisation, and even the whites to hunt and gather too. So when you do those sort of things, it is exercise, there is eating natural foods, there is all that stuff about interacting socially and being motivated to do stuff. And so when we look at the devastation by colonisation that took that away. And then we move into the Mission era and stuff like that when people moved into those reserves and even then they had the whites eat healthy food and given stuff like flour and sugar and fatty needs and all that sort of stuff, but what was lost also was the preparation of food, and how food was prepared and how food has a nutritional side and how it was cooked. And so that was lost. And so we have generations now where some people do not know how to cook. Some people do not know how to even, you know, what is good food, what is healthy food and stuff like that. And then when we move into those like the Missions and the Stolen Generation, there is a whole generation of people who did not have to cook or had to do other things instead of learning how to cook, and as such how to prepare for families and that wider, you know, how to I guess you know, make ends meet and budgeting for food and what is good food. And I think that when you look at today’s society, when you look at the way it is easier to go and buy fast food than it is to go and buy food that you have to prepare, and that way of cooking and that knowledge is being lost, and I think that if you were in that area where a good AMS is, they have those programs to learn how to cook with their food, nutritional value, how it all connects together. And I think there are a lot of factors that you have to take in to that. There is this sort of like level of start dispossession and transgenerational that has been passed down through family to family.

Tim: That is a pretty amazing gallop through some history there. And just to clarify, Chris, that is our patients we are seeing in our consulting rooms now. We talk about this being history, but those are our patients now, aren’t they?

Chris: Yes, they are. And I guess you know, there is just no connection of good nutrition and good food and even to grow food and what does that look like. The knowledge is actually lost.

Tim: And so we can imagine we get our knowledge of cooking from our parents and so with the Stolen Generation that chain of knowledge gets broken. That was the most amazing skip through a couple of hundred years of history that I have heard in a long time.

Chris: There is more.

Tim: There is more. And I think, it is difficult to go into it in a webinar like this and sort of talk about that, and I think each of you will be in places where there is a local history of that among your Aboriginal and Torres Strait Islander patients, that there will be Missions that they were on and will have been moved around. And those are local stories that people will tell, won’t they?

Chris: Yes, local stories. I think that is that stuff around the right to hunt and gather, and that knowledge itself and what that is doing, it does not exist, its gone now.

Tim: Lovely. Okay, um if we move on to the next slide, really talking about the GP’s role. Now this will all be fairly familiar because we are going around words beginning with A again, and we start off by assessing people and assessing what people’s weight is and ask people about their lifestyle and their behaviours and what sort of food they are having. Particularly, when we come to the Go4Fun, what, how the family eats and what the children are eating. Once we have assessed that and we know people’s situation, then we can move on to advising, which is really working with people to see if they can come up with solutions for themselves and what is important to them and what might be practical for them. I always think it is more, you are more likely to be successful when it is a discussion with them coming up with ideas as well, rather than us just telling them what to do. Because then the next stage is that we assist them in being able to do that, so what are the ways about actually implementing that? What are the steps they need to take in order to exercise more or to eat more healthily? What are the barriers to doing this and how can we overcome those and how can we help the family or the person who is mostly preparing food, to do that? And then, one of the main things we will talk about tonight is arranging referral to appropriate lifestyle programs and services. And so one of the ones that we are going to talk about tonight in terms of referrals, is how, is some of those that will be available to all of us across New South Wales now. There will be other local referral services in your area and that it is worth getting onto those as well.

So, we will move on, just thinking about our own role. I think it is worth each of us just thinking how we are currently raising the issue of overweight and obesity among our patients, and particularly our child patients. So if you just want to type in the question box some of the ways you have of asking that, about how you assess people. Someone is just asking about how we talk about food and diet when the usual situation is overcrowding and I think that is something that is a really important point. Overcrowding is common and that does put a barrier on people and we may see if we can get to cover that as well.

So here is one of the examples people approach: “Are you feeling healthy right now?” and someone else: “Can you describe your daily or weekly routine to me please?” and sometimes that is helpful to say whether that is regarding exercise or whether that is regarding what people are eating. And I think getting down to the specifics and saying “tell me what you ate yesterday. Tell me what you had for breakfast. Tell me what you had before lunch. Tell me what you had for lunch. Tell me everything you were drinking”, gets it down to nitty gritty rather than being a vague conversation.

Chris: I think when we talk about family history.

Tim: Yes, so Chris is talking about asking about family history here. Chris?

Chris: Yes, and sometimes people do not know their family history, but sometimes they do not relate their family history to them. And if you say someone has had diabetes, they might say no, but if you said someone had sugar in their family, like sugar in their blood, they might go a different way of conversation with you. I think that is something we have to do because some of us just do not think about family history passing on to them as part of their history.

Tim: Yes. So that is worth being aware of. Also the language we use about that. And I think, so there are a few people here who ask “Are you concerned about your weight?” and someone pointing out that some people do not see obesity as a problem and I think if we think about the stages of change model, some people may not be and we may be able to push them round more to a contemplative than a pre-contemplator, but if they genuinely are not, then that may be something that changes in the future. Someone pointing out that mental health issues are common as well, and that is absolutely right. Social history is good. And I think some of the things that we went through just now as well, some of the specifics around social history, will help. And it think being as specific as possible. So the really good - there is someone asking “Do you have alcohol with your meals? Breakfast?” I think alcohol with your meals and asking about the role of alcohol is important. Breakfast would be a red light. I think it is worth pointing out that there are more Aboriginal people who are teetotal than non-Aboriginal people, so certainly you will find a lot of Aboriginal people who do not drink at all, and you will find some who will drink more than we would advise.

I think what we are seeing here is either relating it to other medical conditions, like some people with sleep apnoea and some people with problems relating to osteoarthritis or heart disease are, I think is going to be a really good way, because it is already causing a problem for people. And finding out about financial status is going to be important.

So I think what you have all demonstrated there, is that you are familiar with discussing this with patients. You do not have a problem raising the issue. You all have ways of raising it, different ways of discussing it with patients, different ways to open up a discussion and I think someone was pointing out that their Maori patients have higher BMIs compared to the Aboriginal and Torres Strait Islander populations, and I think that is true. Medications can of course cause some problems with weight gain. And I think the –Chris has spotted something else on the screen I think.

Chris: Oh no it is okay. I was just looking at the screen.

Tim: Oh yes. That is some of the strategies we have described. Some people will be, might be keen body builders. “Have you thought of getting a few kilos off?” is a good way of phrasing it in a non-medical way. So you have all got ways of talking about this and raising the issue. I wonder if there are any particular ways about raising the issue with children. Because I think that is often a little bit harder than raising it with individuals themselves, because it can be a bit more threatening when it is the child who is overweight or obese. So while you are just thinking about how you might raise it with children, there is an important comment through about when we skirt around the issue or try to be tentative, you are removing agency or power from the patient and infantilising your patient. This is a subject that Aboriginals and Torres Strait Islanders find sensitive to be brought up directly. Any thoughts on that, Chris?

Chris: Oh, I guess just about that relationship again, and I think if you are being honest where you have heard me talk about relationships with patients, and I think that if you have got a relationship, you can be quite direct. And if they have come in for one thing and then the next thing you started talking about their weight or whatever, I think that can get a bit hairy for you as a doctor, but I guess it is building that rapport before you jump straight into it, would be, yes.

Tim: Yes, I think that is right. It does all depend on the relationship. It is difficult to make generalisations about whether people will accept it or not. Some do, some do not. I think the idea of agency and control over your own life is really important because we have actually removed control, the whole history that Chris was talking about, the Stolen Generations, removes people’s control over their own lives. And unless we think about that, we can also do the same when we are sort of telling people what to do and removing control again. So I think it is a really important point.

There are some good comments coming through about raising it with children as well, so about their friends reaction and whether their friends bring up their weight or whether they are teased or bullied at school, and drawing it out on the growth charts as a demonstration of doing it. Whether it affects abilities of daily life like things they love to do like playing sport. So I think those sort of non-judgmental questions about people’s life are really good ways of doing that.

So if we move on now, I think we are going to skip a couple of A’s as that is a lot about the assessment. We have got with us as we heard at the beginning, two people from New South Wales Health who have been very much involved in some referral pathways that we have got. So we are going to skip a few A’s about the programs that are available to refer people to. We might come back to some of the other issues if we have got time. But the reason - the programs that we have available to refer to us, essentially they give us extra, they give us extra arms. Extra hands. Extra time. Where we are actually able to utilise the expertise of other people and the convenience for patients about being able to use some of these programs. And I do not know how many, I think many of our patients including Aboriginal and Torres Strait Islanders patients, do not mind being referred on if there is a trusted service.

Chris: Yes. They do, yes.

Tim: Yes. And this has certainly been, these programs have been thought about. The, I think one of the important things is that they are free and that is always a concern for our patients and they have tried to make it, remember that social gradient slide that I was showing, that have tried to make it so that these programs are accessible to those most in need. And I think it means that it may well be worth, there are some people in most need, who struggle with online or telephone things, where they do not have a stable phone connection or they struggle to keep up with the bills, and that is something that we can ask before our referral. But in theory, they should be very accessible about, in being free and not requiring travel.

So if we move on to the next slide as well. Often after a discussion they are more likely to accept a referral and recognise the need to be, to make changes. And I think as we will see, there are some positive results that come through from the programs that are there at the moment. If you are able to get early benefits, then people get a feedback from that and carry on doing it and as all GPs we receive a report.

Just looking at some of the questions coming through. There is a comment about they have poor follow up record, which I think must be that Aboriginal patients have a poor follow up record. We have not found that to be the case when we are quite active about follow up, so we will send SMS reminders and phone calls to patients to remind them, providing transport to people, which we are lucky enough to be able to do in a community controlled health service, and so our follow up rate is really good actually. I think when we are seeing anyone who is struggling to follow up with us or with other people, there is usually a reason for that, and that may well be that there is so much else going on in their life around housing, around Centrelink, maybe justice issues, family issues, community commitments, that it is actually a real juggling act, school commitments. And so knowing that can help us be more flexible. Some people do not come back if they have had a bad experience in the service as well. Certainly we get to hear about that, and people say “I’m not going back there even if it is a really good service.” So I think it is always worth asking the question, why? Do we have evidence that these services have any difference apart from a social gathering? We do talk about that later on. I think it is worthwhile, so there is evidence in some other things, that the social gathering itself is also beneficial and people do better in social diabetes one on one groups than they do in just one on one. If you look at the Aboriginal Torres Strait Islander definition of health, that is very much a feature of that, being connected socially. And again, the importance of sending a formal report back, we will see that that happens with these programs.

So if we move on to the Go4Fun, which is one of the programs, this is a free and community based program for children above a particular weight. Do one our other speakers want to take over on this one, just to say a little bit more about the Go4Fun?

Jaimee: Sure, I can take over, Tim.

Tim: Thank you.

Jaimee: No worries. So as mentioned by yourself, Tim, a GP referral is often one of the main motivators for a family to join a healthy lifestyle program. So the first two programs we will talk about, Go4Fun and the Get Healthy service, really do rely on that GP referral as one of the main sources of recruitment into the program. So I first just wanted to start by giving a bit of a brief overview about the standard Go4Fun program, just to set the scene before I talk about the culturally adapted version of the program which will be one of the main focusses of tonight. So, Go4Fun is a free healthy lifestyle program for children specifically above a healthy weight, and their families. So the program does not just focus on the children, it really does encourage that whole family approach to making healthy lifestyle changes. And the program is funded by the New South Wales Ministry of Health, so it is completely free of charge for participating families. The aim of the program is to support families in adopting a healthy lifestyle by improving their dietary habits, increasing physical activity, fitness and confidence as well. So I just want to emphasise that the program is really around increasing healthier lifestyles. It is not a diet and it does not focus on weight or weight loss either. The program is delivered by qualified health professionals, so for example dieticians, exercise physiologists, nurses et cetera. And just before I talk about the eligibility criteria, I just wanted to touch a little bit more about the program structure. So the program runs once per week for ten weeks in line with the school term. Each session lasts for two hours and in the first hour, the children and the parents are together and they learn about nutrition and healthy eating. So each week, they learn about a different topic, so for example, it might be every day and sometimes foods or fats and sugars. In the second hour, the group actually splits off, so the children will go with a physical activity leader and play some really fun games based on physical activities, and the parents stay together and participate in a facilitated discussion around behaviour change. And this session I think is really important as it gives the parents an opportunity to discuss issues which they might not feel comfortable talking about in front of their children.

So on this slide you can see that there are some eligibility criteria for families to participate in the program. So to be eligible, families must live in New South Wales. So they must have a New South Wales address. Their child must be aged between 7 to 13 years and be above a healthy weight. So above or equal to the 85th BMI percentile for age and gender. And as I mentioned, it is a family based program so a parent or carer must attend each session.

Tim: It’s Tim here. I was just going to add, when I first saw these slides, I commented, I looked at the pictures of the children and said, “Oh, we will have to change that picture, they are not above the 85th BMI percentile”, and they all are. And I was struck by how difficult it is to tell just by looking. So it is worth measuring that and plotting it on the chart. I think I was misled.

Jaimee: That is right, Tim. I think a lot of people probably, it is quite hard to identify whether a child is above a healthy weight, so that is where those measurements do come into play. And so programs are delivered through the Local Health Districts and the program has been around since 2009. And so during this time, since 2009, the data has shown that the program, the mainstream program, has actually reached a significant number of Aboriginal families, so approximately 9% of all participants identify as Aboriginal or Torres Strait Islander. However the consensus among some of the key stakeholders around the program, was that more could be done to improve participation and outcomes for these families. So as a result, in 2015, the Ministry of Health commissioned a cultural review of this program in order to deliver a program which is more culturally appropriate for our Aboriginal families and communities. And this process was done by an Aboriginal consultancy company with advice and input from an Aboriginal-led advisory group and the Local Health Districts. As a result, the culturally adapted Aboriginal Go4Fun program was developed and this program has a number of really unique features which are distinct from the mainstream program. And one of the key differences, is the mode of delivery. So one of the key recommendations from the cultural adaptation process was that there was a need for a really strong Aboriginal leadership presence for the ongoing success of the program. Therefore a co-delivery model was introduced and in this model the Local Health Districts were actually in formal partnership with a local Aboriginal organisation such as an AMS to co-deliver the program. And this model really aims to draw on the strengths of both parties to provide a really successful program for the families. And one of the key focusses of this model is to actually build the capacity of the Aboriginal organisation to eventually one day take on the program delivery responsibilities. So the program also has a much more inclusive approach than the standard Go4Fun program. So while the primary target audience is still the same, so children aged 7-13 years who are above a healthy weight, there is a much stronger emphasis on Aboriginal community participation, so that siblings, extended family and friends who might not necessarily meet the eligibility criteria can also participate. And this approach was recommended to not only encourage greater participation but also as a reflection of the strong family values in Aboriginal communities. And obviously our target audience is Aboriginal families, however non-Aboriginal families are also able to attend the program as long as they are aware that the program has been tailored specifically for Aboriginal families.

Sorry, Tim?

Tim: I have just got a question come through which I think is a good question. Do people need Medicare to be referred?

Jaimee: No, they do not.

Tim: So they will need Medicare if you, if they want to see you, or to get a rebate for seeing you, but they do not need Medicare to be referred to this? Yes. And then they also asked about the timings on average for parents working? I think you said there was a two hour face to face, was it?

Jaimee: It is. So it is two hours once per week and it is usually after school. So usually 4-6 or 5-7 pm.

Tim: That is great. Thank you.

Jaimee: No worries. So just a bit more on the key features of the program. There is quite a lot of flexibility within the delivery model as well, so that the local delivery team can really tailor the program to best suit their group. So, they might decide to alter certain activities or the way that information is presented to a way which will really suit their group. There is also Aboriginal-specific content and design and a focus on experiential learning as well. There is also lots of support for the leaders, helping with program planning, delivering sessions and also working with Aboriginal families.

So the next slide just has some images of some of the resources which families will receive throughout the program. So on the left-hand side you can see that each participant throughout the duration of the program will receive a t-shirt to wear, a drink bottle, a back pack, a ball and a Frisbee. And all of these resources are actually really well received, especially the t-shirt. Delivery teams also have the ability to provide additional incentives to families, so for example they might want to give supermarket voucher or a fruit and vegetable box to encourage attendance at the program as well.

So this slide just has some of the outcomes of the program. So, between January and December 2017, there were a number of programs delivered across a range of different areas as you can see on the slide. So Local Health Districts and Aboriginal organisations from Airds, Redfern, Grafton, Ballina, Kempsey, Coffs Harbour, Orange, Nowra, Mungindi, Maitland and Moree have been involved in the program and many more as well. And as you can see, there is a good mix of metro, regional and rural New South Wales. And on average, participants have shown a reduction of 0.5 in their BMI and 0.9 cm in their waist circumference. Almost half the participants showed an increase in daily fruit intake, 59% showed an increase in vegetable intake, and 61% decreased their sugary drink consumption which is huge. And almost half the participants increased the number of days they were meeting the physical activity guidelines and 44% decreased their sedentary time as well.

Kate: Hello everyone, this is Kate speaking. I am the manager of the Get Healthy service. So we have taken some time to talk a little bit about the Go4Fun program which works with children and families, but I am going to just give you a little bit of an overview of the Get Healthy information and coaching service. So this actually focusses on New South Wales residents who are 16 years and over. But for those of you who are on our borders, there is also a service in Queensland and also in South Australia.

So this service is free of charge as we have discussed and provides confidential telephone based information coaching service. We have a new provider, so some of you may have experienced the service before. But we have a new provider and we have updated the coaching model. It was previously a little more scripted, but now it is a lot more responsive to the coaching participant and we are getting some great feedback that people are enjoying the experience a lot more. So it supports participants to achieve healthy lifestyle, obviously focussing on things like healthy eating and physical activity. We also look at alcohol reduction and I will talk a little through our branches about abstinence in pregnancy and healthy gestational weight gain for any of your pregnant patients, and also looking at reaching and maintaining a healthy weight. So as Tim has said, really this is meant to compliment clinical care and in terms of duty of care and clinical governance, we have a very strong clinical governance structure so patients who are identified at risk will be referred back to their GP, potentially for initial sign-off, but also if they notice that they are having for example problems with their asthma or there is a particular issue with their mental health. These people will be referred back to you. The service is delivered by university qualified health coaches, so we have dieticians, exercise physiologists and these are also trained in health coaching specifically. We have now some nurses as well and they also get a lot of particular training, for example all our health coaches have just had an update on how to apply coaching for people with lower back pain. So we also are increasingly looking at how we can meet the needs of specific populations and tailor things to really meet individual needs.

So there are two levels of service that we offer, because we really recognise that it is not a one size fits all for different people. So we offer an information only service which we find some people will take up. They will get an information booklet. They get one-off coaching advice and some people find that this is all that they are really wanting at this time. And we find quite a lot of people will initially take potentially the information only option and they will enrol in coaching at a later stage. So often that is something that a GP might encourage them with, that potentially people will have lots of things going on in their life and it is not a good time for the coaching, or they are just not ready yet, but that at a later stage, they will enrol. So the coaching itself, the generic coaching is ten free coaching sessions over six months. They have their own coach so they speak to the same person each time, and they set their own goals. Again, they get the information either electronically or paper-based and they can re-enrol following completion and we have a cohort of people who really will dip in and out of the coaching service; that they will do very well initially and then they will need to come back at a later stage when they start to fall back into old habits. So we have a number of streams, so that you can select where you send people, and each of these streams can be tailored particularly for your Aboriginal and Torres Strait Islander patients. So we have the standard program. We also have a special stream for type 2 diabetes prevention, for those who you recognise are at risk of developing this, or are already suffering from type 2 diabetes. We have a particular module for alcohol. So one of the things with the alcohol. This is for people who are at low risk, who are maybe just having a few more glasses than what you would like for their health. We have a module that particularly focusses on them. We have Get Healthy in Pregnancy and Alcohol Abstinence in Pregnancy and of course we have our specific Aboriginal program.

So I will talk a little bit about the Aboriginal specific program. So one of the big things that we now have on offer which we are finding is making a big difference is that we have an Aboriginal liaison officer now. This is a lovely woman who is an Aboriginal nurse. She is a health coach herself and she will actually do the coaching with many of our Aboriginal clients, but even in cases if she has too much volume, she will broker the relationship with Aboriginal clients and make that initial call. So our Aboriginal and Torres Strait Islanders get a little more time. They get 13 coaching calls in total and we find that they respond from the feedback on results and what they have said is to have a few more calls early on and then these taper off towards the end of the six months. There are specific promotional and course materials that have been developed in consultation with Aboriginal community members that really speak to them and meet their needs. And particularly note for your Aboriginal and Torres Strait Islander women who are pregnant, that we respect women’s business and they have female only coaches and where possible the Aboriginal liaison officer who is a nurse will often conduct that coaching and we are finding that really is making a big difference for these people.

So just to give you a very brief overview of potentially if someone is asking you about what happens, when does it happen? So on referral and we will talk through some referral means at the end, they will get a call for Aboriginal patients within the first 3-5 days, then with that registration call it takes about 15 minutes and is with the Aboriginal liaison officer. They can choose whether they want information only or whether they would like to progress onto coaching and they get to set up the times would be appropriate for them. We also now have some SMS messaging which we find people really like because they can reset their coaching times if they want to. They get information, the coaching calls start, and the coach and the participant really set when those coaching calls will occur. They make it at a time that suits the person and they can by SMS or by calling change the time. We really find this gets much better engagement. On graduation, they get a recipe book and I will talk through a little bit some of the results.

So we have - the program has been running since 2009 and we have had 52,000 people through the service and we have learnt a lot in that time, and refined the service in that time. So, particularly looking at the Aboriginal participants who completed the coaching, they showed really some significant improvements. So the average weight loss was actually 4 kg and they lost 7 cm off their waist. So I am sure as you would all know, this has some significant health implications and is really a great result, particularly we have also seen some changes around fruit and vegetable consumption. This increases and also, a decrease in the amount of take away meals people are consuming, and also sweetened drinks, with people tending to drink more water. And I will talk a little bit more later on about the Knockout program and what a good introduction to some of these other things it is. So we see increases in physical activity levels and particularly we see people having a really high level of satisfaction with the program and that advice was provided that was sensitive to their needs and particularly their personal situation and that the coaches really have a good understanding of what is practical and easy to do within their community and where they are living with their constraints. So the coaches provide for example, information on fruit and vegetable consumption and meals that really is sensitive to their socioeconomic status, what they can afford and particularly in some of those remote areas, what they might actually have access to.

Jaimee: So there are two ways that families can enter these programs. One of the main ways is by self-referring. So they can jump on line at Go4Fun.com.au or Gethealthynsw and register to each of the programs, or they can also call the centralised service provider numbers which are up on the screen as well. But one of the main ways that families do enter these programs is through health professional referral and they are the second highest form of referral into our programs at about 15%. And so we will talk about each of these different ways of referring in the next few slides.

So you can find the referral forms in some of your medical software. So, Go4Fun and Get Healthy service are in the Medical Director software. If you look under the supplied templates tab and scroll down alphabetically to referral form, you will be able to find Go4Fun and also the Get Healthy service. And then you just click through and start to manually enter your patient’s information. So that is just an image of what the Get Healthy service referral template would look like in Medical Director. In Best Practice, it is quite similar. You search for Go4Fun or Get Healthy service and then you need to actually select your patient from the database and then enter their details into the referral forms. You can also order some hard copy referral forms by calling the centralised service provider numbers or through our websites. You can also order brochures, magnets and other posters for your practice as well. So another source of referring patients in through the Healthy Kids for Professionals website. And so this website is actually quite new and it was developed by the Ministry of Health last year and it has a range of resources on there for health professionals. But to find the Go4Fun and the Get Healthy referral forms, you click through to the “arrange” tab and then you will find the referral forms there as well as more information about the programs and other promotional material.

Kate: Probably the only thing, this is Kate speaking, I would say in terms of referring patients, we found that it really makes a big difference if the referral comes from the GP, that people really see this as then important, that their GP is often a really trusted source of advice. So I really encourage you, even though you can send your patients away and recommend to do the referral, that really doing it with them or potentially if you have a practice nurse getting them to do it with the patient, you can also just call up with the patient there and do an introductory referral as well. So I cannot iterate that strongly enough, that really that is one of the reasons we are talking to you, is that you are a really key touch point for people and a trusted source of advice, so we really value that and I think really the patients really value your medical expertise and recommendations they take fairly seriously.

Tim: The other thing that is worth pointing out, someone asked the question earlier which I answered by text, but these are, do not count towards the GP management plan team care arrangements of the Aboriginal Health Assessment Allied Health Sessions, so it does not use those up, so it is sort of extra things that you can get for your patients or that you can get if they are not eligible for say a GP management plan or something. So I think that is another useful way in for patients.

Jaimee: So we just wanted to touch on the type of feedback that you as a referrer will receive, and we have gotten a few comments in the chat box about the type of follow up and type of information that you do get, so this is just some information on the type of communication which is provided. So once you do refer a patient, you will receive updates along the way on their progress throughout the programs. So you will receive a report once they actually register for the program and another one once they complete. And this kind of outlines the results that they have achieved along the way. And if your patient has registered for the Get Healthy service, you also receive a mid-point report as well. You are also notified if they actually withdraw from the program and if they decide to decline GP updates as well.

Kate: We have really worked on this. We know that there were some inconsistencies in GPs getting reports in the past, but we have really ironed that out, hopefully to a large degree, so also if you know you should be getting a report and you are not, please let us know, but really we are hoping that this is pretty consistent now, that you will get these reports coming back to you as soon as the person is enrolled.

Jaimee: So the next few slides just have some examples of the type of letters that you will receive. So these are specifically for Go4Fun, but Get Healthy are quite similar. So this one is a pre-program report. So once a family has registered you will receive a report that has their details in it, so you have got height, weight, waist circumference and their weight status which is also plotted on the BMI graph.

The next slide has the post-program communication. So you get a really brief one summary document with some of the main outcomes such as fruit and veg intake, water, physical activity and BMI, but also a more detailed report with these outcomes and additional ones that you can read through as well.

Kate: Hi, this is Kate again. As well as doing the Get Healthy program, I also manage the New South Aboriginal Knockout Health Challenge, and I am not sure how many of you are aware of this, but really it is a very innovative way to reach Aboriginal communities and really make sustained changes to the lifestyles of people within those communities. So it is led, this program is led by the communities themselves and it focusses on healthy lifestyle and weight loss and it is actually a competition and is very popular amongst Aboriginal communities who have participated. So it occurs twice a year and it occurs over ten weeks. So I will talk you through a few more of the details. So, one of the things that it does is really get Aboriginal communities to really invest in themselves and we really find that the social connection that it provides is really key. We have a Facebook page and it is the most used Facebook page really in the Ministry of Health. The numbers are small, but people are very actively engaged. And one of the problems we have found is that people really trust suggestions from their peers and this competition is really a way we get people sharing healthy recipes, healthy ideas, and exercise ideas with each other that really resonate with people. So we found it really is a great way forward. Teams receive $1,000 to start off. Often they buy things like exercise equipment. In this challenge we have sponsored them to run cooking sessions and these are not just for people in the competition. These are for the whole community. So really, teaching people from the grass roots how to cook healthy food. I know Chris you mentioned that is some of the issues, sometimes they can use local foods and really, really learn how to cook those healthy foods. So that has been a really popular way of spending those funds and we have further supported that. We are also supporting participants with coaching and we will be training a whole lot of coaches on how to get people physically active within those communities. So really getting them in for the future. So they form teams and they can have up to 30 Aboriginal participants. They can get their mates who are non-Aboriginal in as well, but they just do not count towards the competition. But some teams have quite a good mix and there is a lot of comradery in it. We do have a GP sign off prior to entering the competition and that is not just as duty of care, though that is obviously very important, but really, really it links people in with the health system and that is one of the key aims, is really not only the health direct benefits but also linking people up and giving them experience. Often a dietician might come and talk, linking them in with their GP. We really encourage participants to have their annual 715 check when they go in to get their GP sign off and also they verify their weight. So that is also a good way for the challenge, but also it is a good introductory talking point for the GP as well. One of the other things is, it is a great entry point to some other things, so the Get Healthy service does not provide coaching like Quit Line, but this is a referral point on to Quit Line and also onto the Get Healthy service.

So, I will talk a little bit about the outcomes for this group. And I think it is really important to talk about how they are direct and indirect. There have been approximately 1,200 participants and there are over 40 communities across New South Wales who participate. It is great because it really gets to rural and remote communities. The average weight loss is 2.3 kg and they are increasing their fruit and vegetable intake. And we really see a big improvement in high levels of physical activity. And some of the non-formal things are really that the competition gives a community a good sense of what is healthy. Often kids will come along and observe and we have noticed that families start to exercise a lot more together, not just the people in the competition and eat more healthily at home during it. The challenge they can enter more than once, and we often find that people will go into the competition multiple times and gradually over a longer period of time lose weight more and more.

So, if you are out there and you are keen to refer your patients in, we do have another challenge coming up later this year. So the next challenge goes from the 3rd September to the 9th November with registrations closing on the 17th August. So hopefully some of you will have some of these people coming in for sign off, but I would really encourage your Aboriginal and Torres Strait Islander patients into the challenge. Often we have new groups, even if they are only small who will have a go the first time and then go in the competition later on. But the feedback from the community is very supportive and I think we have all talked about that social support being key and within this program that is working very well. We have a new provider who is an Aboriginal organisation and there is quite strong links to rugby league which really resonates well with these communities.

Jaimee: So we might just skip through this slide, but it is just to say that Get Healthy and the Aboriginal Knockout challenge participants are able to enrol and there is no limit on the number of enrolments. Go4Fun is a little different just because there is standard and set content and re-entry is allowed with a health professional referral or otherwise judged on a case by case basis.

Tim: Thank you very much. We have just come to the end of our time and this is just to reiterate really the GPs role. As we talked about before, but adding in some of the bits that we have heard about with the referral program and it is good to know that special effort has been made on the feedback to ourselves from the programs. To summarise really, the first to, the Go4Fun and the Get Healthy program are ones that we can refer to and I would encourage you to refer to. The Knockout health challenge is more something that we might come across if the communities we are working in are taking part, and then people will come to us asking for a weight check and it is an opportunity to do a 715 Medicare health assessment as well.

There have been quite a few questions come through. The last slide just goes over the learning outcomes again. There have been a few questions and comments come through that we have not got time to into right now, because the end of our time has come up, but we do usually take these questions and answer them separately outside the program. So Chris, is there anything you would like to say to finish off?

Chris: I think that when you talk about participating in a community and that eagerness to get people to actually think about their health, I think doing that in Aboriginal communities, I think that doing it in a group sort of situation is much more better than an individual. It’s the thing about supporting other and sharing ideas and being there every week, so yes, have a go at it.

Tim: Yes, certainly. Thank you very much Chris. Thank you Sammi for running everything so well behind the scenes as well and making it all run smoothly. That is a reminder of the learning outcomes. We do hope that is what we have achieved tonight. Have a wonderful rest of the evening. Thank you Kate and Jaimee as well.

Kate: Thank you.

Jaimee: Thank you.

Sammi: Thank you again for joining us. I hope you enjoyed the session, and enjoy the rest of your night.